Surgical treatment may improve depressive and hysterical traits in temporal lobe epilepsy with hippocampal sclerosis: Study using the Minnesota Multiphasic Personality Inventory.

Aim: The influence of surgeries on psychiatric symptoms and personality traits is not well known in patients with intractable temporal lobe epilepsy (TLE). We investigated changes in personality traits with respect to postoperative seizure outcomes, etiology, side of surgery, and sex differences. Methods: Clinical information was retrospectively collected for 44 patients whose Minnesota Multiphasic Personality Inventory (MMPI) was examined before and 1 year after surgical treatment for drug-resistant TLE. Postoperative changes in MMPI T-scores were analyzed using a paired t-test. Participants were divided into two groups based on postoperative seizure outcome, the presence or absence of hippocampal sclerosis (HS) as the etiology, side of surgery, and sex differences. The effect of these clinical factors on postoperative changes in MMPI T-scores was evaluated using analysis of covariance (P-values < 0.05). Results: The hypochondria (Hs) scale decreased significantly in all patients (p = 0.022). The postoperative seizure-free group had a significant decrease in the depression (D) scale (p = 0.037). The HS group had significant decreases in the D scale and the hysteria (Hy) scale (p = 0.016 and 0.004, respectively), and a significant increase in the masculinity-femininity (Mf) scale (p = 0.009). No significant differences existed between the sides of surgery or sex. Conclusion: Depressive traits were improved in patients with postoperative seizure freedom. Depressive and hysterical traits were improved in patients with HS, which may be attributed to a reduction in anxiety and fear associated with aura. Most personality traits are not significantly changed or exacerbated by surgical treatment of TLE.

Double inversion recovery MRI of subcortical band heterotopia and its variations.

BACKGROUND AND PURPOSE: Subcortical band heterotopia (SBH) is a malformation of cortical development diagnosed via MRI. Currently, patients with SBH are classified according to Di Donato's classification. We aimed to show a variation of SBH and the usefulness of double inversion recovery (DIR) images. METHODS: We retrospectively reviewed the MRI findings of 28 patients with SBH. The patients were classified according to Donato's classification by using conventional MR images, and their DIR findings were reviewed. RESULTS: Of 28 patients, 20 were grade 1 and 8 were grade 2 according to Di Donato's classification. In 15 of 28 patients, the following four types of atypical MRI findings were detected: asymmetry distribution (four cases), coexistence of thin and thick SBH (five cases), and DIR faint abnormal signal intensity in subcortical white matter (five cases) and in deep white matter (five cases). The latter two types were detected on DIR alone and have not been reported. Additionally, these were identified only in the mild group (Di Donato's classification 1-1 or 1-2). CONCLUSION: DIR is a useful MRI sequence for detecting faint white matter signal abnormalities, and it can aid in the accurate classification of SBH and identification of its variations, which may reflect the pathology of SBH.

Criminal victimization of people with epilepsy: Sixteen criminal judgments in Japan between 1990 and 2019.

Criminal behavior by people with epilepsy (PWE) has often been discussed. However, there are limited studies on criminal victimization of PWE-in particular, how such victimizations occur. We identified criminal cases involving victims with epilepsy using databases containing criminal judgments and found 16 such cases between 1990 and 2019. Seven were homicide cases, including four filicide cases. In the four filicide cases, all the perpetrators had the intention of homicide-suicide; all the victims had intellectual disabilities or cerebral palsy; two of these victims had acted violently toward the family; and two mothers who perpetrated the crime against the victims had depression. It seemed that the comorbidities and problem behaviors of the victims were more strongly related to serious crimes by family caregivers than the epilepsy itself. To prevent victimization caused by family caregivers, reducing their stress levels is important. Defendants sometimes argued against objective evidence of a crime, claiming that epileptic seizure of PWE caused or was related to the death of victims. Legal and medical professionals involved in determining the manner of death need careful evaluation when sudden deaths of PWE occur.

Long-Term Undiagnosed Nonconvulsive Status Epilepticus Identified by Urgent Electroencephalography with Hyperventilation Activation.

Nonconvulsive status epilepticus (NCSE) might be underdiagnosed in cases where clinical symptoms are ambiguous. If a patient exhibits ictal psychiatric symptoms such as NCSE presentation and is misdiagnosed as having a psychiatric disorder, the patient may be treated in psychiatry settings, where continuous electroencephalography (cEEG), the gold standard for NCSE diagnosis, is typically not used. Herein, we report our experience with a patient having NCSE who exhibited psychiatric symptoms and remained misdiagnosed for many years. We also included a brief review of the relevant literature. Our experience with this patient presents two clinically significant points: (1) clinicians should consider NCSE in the differential diagnosis of interictal psychosis when patients with epilepsy, in whom the seizure type is unknown, repeatedly present transient psychiatric symptoms, and (2) urgent EEG with hyperventilation activation during acute periods may help diagnose patients with suspected NCSE.

Improvement in anti-N-methyl-d-aspartate receptor antibody-mediated temporal lobe epilepsy with amygdala enlargement without immunotherapy.

Focal neuroinflammation is considered one of the hypotheses for the cause of temporal lobe epilepsy (TLE) with amygdala enlargement (AE). Here, we report a case involving an adult female patient with TLE-AE characterized by late-onset seizures and cognitive impairment. Anti-N-methyl-d-aspartate receptor (NMDAR) antibodies were detected in her cerebrospinal fluid. However, administration of appropriate anti-seizure drugs (ASD), without immunotherapy, improved TLE-AE associated with NMDAR antibodies. In the present case, two clinically significant observations were made: 1) anti-NMDAR antibody-mediated autoimmune processes may be associated with TLE-AE, and 2) appropriate administration of ASD alone can improve clinical symptoms in mild cases of autoimmune epilepsy.

A case of interictal dysphoric disorder comorbid with interictal psychosis: Part of the same spectrum or separate entities?

Depressive disorders in epilepsy often present characteristic clinical manifestations atypical in primary, endogenous depression. Here, we report a case of a 64-year-old woman with right mesial temporal lobe epilepsy, who complained of bizarre, antipsychotic-refractory cenesthetic hallucinations in her interictal phase, and was hospitalized after a suicide attempt. Detailed clinical observations revealed mood symptoms, which led to the diagnosis of interictal dysphoric disorder comorbid with interictal psychosis. Sertraline with low-dose aripiprazole markedly alleviated both depressive and psychotic symptoms. This case suggested that the two diagnostic entities may overlap and that depressive symptoms tend to be concurrent when concurring with psychosis, which hampers the appropriate choice of a treatment option.

Periodic Slow Waves Presenting as Ictal Electroencephalography Findings in Complex Partial Status Epilepticus.

The diagnosis of nonconvulsive status epilepticus (NCSE) largely relies on electroencephalography (EEG) findings, but the existing diagnostic criteria for EEG results are sometimes inconsistent. Much debate has centered on periodic epileptic discharges (PEDs) and their relationship with seizures. The recently published Salzburg Consensus Criteria for diagnosis of NCSE, which consider PEDs to be ictal findings under several conditions, have been proven to have high diagnostic accuracy. However, the criteria do not include periodic slow waves (PSWs) and do not consider these as overall ictal electrographic changes. Here, we report 2 cases of complex partial status epilepticus in which routine EEG showed PSWs without epileptiform activity during the clinical ictal phase. Both patients were elderly males who had histories of seizures and presented with impaired consciousness and signs such as aphasia or tongue automatism that indicated a temporal lobe origin. After we administered antiepileptic drugs (AED), the clinical signs and periodic EEG slow waves disappeared. These cases show that PSWs may appear as ictal electrographic changes in NCSE. When PSWs accompany clinical signs suggestive of NCSE, they should be considered ictal findings, and physicians should administer AED.

Emotional stimuli-provoked seizures potentially misdiagnosed as psychogenic non-epileptic attacks: A case of temporal lobe epilepsy with amygdala enlargement.

The association between emotional stimuli and temporal lobe epilepsy (TLE) is largely unknown. Here, we report the case of a depressed, 50-year-old female complaining of episodes of a "spaced out" experience precipitated by emotional stimuli. Psychogenic non-epileptic attacks were suspected. However, video-EEG coupled with emotional stimuli-provoked procedures and MRI findings of amygdala enlargement, led to the diagnosis of left TLE. Accurate diagnosis and explanation improved her subjective depression and seizure frequency. This case demonstrated that emotional stimuli can provoke seizures in TLE and suggested the involvement of the enlarged amygdala and the modulation of emotion-related neural circuits.

Depression in people with epilepsy: How much do Asian colleagues acknowledge it?

PURPOSE: The purpose of this review was to investigate the prevalence of depression in people with epilepsy (PWE) in different countries in Asia. METHODS: We searched the electronic database PubMed on June 13, 2017 for articles in English that included the following search terms: "epilepsy" AND "depression" AND "country name" for all Asian countries since 1947. Relevant original studies from Asia were included if they reported the prevalence of depression in PWE. Papers studying special populations (e.g., elderly, veterans, etc.) were not included. In addition, experts in epilepsy field were invited from some Asian countries for an in-depth assessment. RESULTS: Six hundred eighty-seven papers were reviewed and 26 related studies were included in this study. Depression is highly prevalent in PWE in different countries in Asia and the prevalence rates are consistent with rates reported in the literature from other countries: overall, about 25% of PWE suffer from depression. CONCLUSION: In Asian countries, as elsewhere, depression is common in PWE. High quality data is scarce in many countries and validated screening tools [e.g., Neurological Disorders Depression Inventory for Epilepsy (NDDI-E)] to appropriately investigate the prevalence of depression in PWE are still lacking in many languages. Considering the high prevalence of depression among PWE, routine and periodic screening of all PWE for early detection and appropriate management of depression would be a reasonable approach.

Marked accumulation of oligodendroglia-like cells in temporal lobe epilepsy with amygdala enlargement and hippocampal sclerosis.

Although an increasing number of cases of temporal lobe epilepsy (TLE) with ipsilateral amygdala enlargement (AE) have been reported, there are few pathological reports, and no clear consensus has been established. Oligodendroglia or oligodendroglia-like cells (OLCs) have recently attracted attention in epilepsy studies. Here, we report the clinical and pathological findings of a 40-year-old male TLE patient with AE and hippocampal sclerosis, in whom histopathological study demonstrated remarkable clustering of OLCs around the uncus. The patient began to have refractory seizures at the age of 14, and preoperative MRI revealed left amygdala enlargement and left hippocampal atrophy. Other examinations were consistent with left mesial temporal epileptogenicity. He underwent surgical resection and achieved seizure freedom. Histopathological study of the amygdala showed swollen neurons with relatively large bodies and thick neurites, accompanied by vacuolar degeneration in the background. Additionally, there were marked clusters of OLCs with round nuclei and densely stained chromatin around the uncus. The OLCs were Olig2-positive. In the hippocampus, severe cell loss in CA1 and granule cell dispersion in the dentate gyrus were found. These findings may provide some insights for further pathological investigations of TLE with non-neoplastic AE.

A novel mutation of NFIX causes Sotos-like syndrome (Malan syndrome) complicated with thoracic aortic aneurysm and dissection.

Malan syndrome has recently been characterized to present Sotos-like phenotypes, such as intellectual disability and macrocephaly, with mutations in the NFIX gene. Herein, we report a 38-year-old patient with a novel single adenine insertion mutation in exon 2 of the NFIX gene (c.290_291insA). He developed early-onset thoracic aortic aneurysm and dissection, which was a rare complication but deserves particular attention in relatively long-lived patients with Sotos-like phenotypes.

PNES around the world: Where we are now and how we can close the diagnosis and treatment gaps-an ILAE PNES Task Force report.

An international consensus clinical practice statement issued in 2011 ranked psychogenic nonepileptic seizures (PNES) among the top three neuropsychiatric problems. An ILAE PNES Task Force was founded and initially charged with summarizing the current state of the art in terms of diagnosis and treatment, resulting in two publications. The first described different levels of diagnostic certainty. The second summarized current knowledge of management approaches. The present paper summarizes an international workshop of the ILAE PNES Task Force that focused on the current understanding and management of PNES around the world. We initially provide a knowledge update about the etiology, epidemiology, and prognosis of PNES-in adults and in special patient groups, such as children, older adults, and those with intellectual disability. We then explore clinical management pathways and obstacles to optimal care for this disorder around the world by focusing on a number of countries with different cultural backgrounds and at very different stages of social and economic development (United Kingdom, U.S.A., Zambia, Georgia, China, and Japan). Although evidence-based methods for the diagnosis and treatment of PNES have now been described, and much is known about the biopsychosocial underpinnings of this disorder, this paper describes gaps in care (not only in less developed countries) that result in patients with PNES not having adequate access to healthcare provisions. A range of challenges requiring solutions tailored to different healthcare systems emerges. Continued attention to PNES by the ILAE and other national and international neurologic, psychiatric, and health organizations, along with ongoing international collaboration, should ensure that patients with PNES do not lose out as healthcare services evolve around the world.

[Role of Departments of Psychiatry in University Hospitals as a Developer, Provider, and Educator of Innovative Clinical Psychiatry].

The roles of university hospital psychiatric departments are: 1) the development and pro- vision of advanced psychiatric treatments unique to university hospitals, 2) the provision of psychiatric intervention models for patients with physical diseases, and 3)the provision of real- world environments for young psychiatrists to learn the principles and experience the practice of such innovative care. As for 1), our facility offers a hospitalization for examination program, which uses near-infrared spectroscopy as a biomarker useful for the auxiliary diagnosis of psy- chiatric disease and selection of the treatment method. University psychiatric departments also play a major role in neuropsychiatry, such as through the use of Epilepsy Monitoring Units (EMU) to differentiate between epilepsy and psychogenic non-epileptic seizures (PNES). Additionally, hospitalizations for examination programs are being implemented for psychosocial and employment support for psychiatric patients, and the diagnosis and evaluation of develop- mental disorders. With regard to 2), our facility has a psychiatric liaison-consultation team. In addition to providing consultation for all departments on delirium, anxiety, and depression, they are actively committed to various transplant treatments. There is also a strong cooperative relationship between the critical care center and psychiatric department. Of the patients hospi- talized for physical conditions and emergencies, over ten percent require psychiatric support, and without the psychiatric department, many patients with severe physical diseases cannot be treated. As such, the medical fees for psychiatric departments in universities and general hospitals should be evaluated appropriately. We would like to propose an "Advanced Psychiat- ric Treatment Development Management Center" (tentative name) to manage the following cycle : a) every university psychiatric department will develop and offer model projects utiliz- ing their respective expertise and specialties ; b) after collecting information on best practices, they will establish evidence through multicenter research, Diagnosis Procedure Combination (DPC) data, and others ; c) they will progress to advanced medical treatments and insurance coverage ; and d) they will continue to improve quality. Finally, I emphasize the role of univer- sity psychiatric departments as the center of education where young psychiatrists learn the principles and experience the practice of such an advanced care model, which will innovate and reform future mental health care.

A case of autoimmune epilepsy associated with anti-leucine-rich glioma inactivated subunit 1 antibodies manifesting electrical shock-like sensations and transparent sadness.

Autoimmune epilepsy is an isolated phenotype of autoimmune encephalitis, which may be suspected in patients with unexplained adult-onset seizure disorders or resistance to antiepileptic drugs (AEDs). Antibodies against leucine-rich glioma inactivated subunit 1 of the voltage-gated potassium channel (VGKC) complex, recently termed anti-LGI-1 antibodies, are one of the causes of autoimmune epilepsies. Bizarre symptoms with extremely short duration and high frequency are clues to the possible presence of autoimmune epilepsy with anti-LGI-1 antibodies. Precise diagnosis is important because autoimmune epilepsy is treatable and the prognosis can be predicted.

Evaluation of amygdala pathology using (11)C-methionine positron emission tomography/computed tomography in patients with temporal lobe epilepsy and amygdala enlargement.

OBJECTIVE: The association between amygdala enlargement (AE) and temporal lobe epilepsy (TLE) has increasingly been reported. However, the pathology of AE remains poorly understood. The purpose of this study was to explore AE pathology using (11)C-methionine (Met) positron emission tomography (PET)/computed tomography (CT) in patients who have TLE with AE. MATERIALS AND METHODS: Twenty-six TLE patients with AE and 18 TLE patients without AE underwent (11)C-Met PET/CT and magnetic resonance imaging (MRI). (11)C-Met uptake in amygdala was evaluated by both visual inspection and semi-quantitative measurement. MRI was assessed visually and semi-quantitatively for AE. Laterality index (LI) was obtained by comparing the amygdala volumes of ipsilateral and contralateral sides. The clinical course and histopathological findings of all patients were also analyzed. RESULTS: On (11)C-Met PET/CT images, visual examination detected increased uptake in the enlarged amygdala in 7 of 26 (27%) TLE patients with AE, and the results were confirmed by semi-quantitative analysis. Among six TLE patients with AE who underwent surgery, histopathology revealed neoplasms (low grade astrocytoma and gangliocytoma) in two patients and focal cortical dysplasia in one patient with increased (11)C-Met uptake, but non-neoplastic lesions (focal cortical dysplasia, vacuolar degeneration, and hamartoma) in all three patients with no increased (11)C-Met uptake. On MRI, volume of the affected amygdala was significantly larger compared to the contralateral amygdala. LI was significantly higher in the group with AE than in the group without AE. CONCLUSIONS: This study revealed that some TLE patients with AE showed increased (11)C-Met uptake in the enlarged amygdala. (11)C-Met PET/CT is potentially useful for the evaluation of AE pathology, and may provide beneficial information for appropriate decision-making.

Nonconvulsive status epilepticus in the elderly associated with newer antidepressants used at therapeutic doses: A report of three cases.

Classic antidepressants have been known to induce convulsive seizures and nonconvulsive status epilepticus (NCSE). On the other hand, many reports have emphasized the safety of novel antidepressants. However, we encountered three cases of NCSE in the elderly associated with the use of newer antidepressants at therapeutic doses. All three patients were male and were 73 years of age or older. One patient was recently diagnosed with temporal lobe epilepsy and treated with low-dose lamotrigine. In all patients, newer antidepressants were initiated because of depressive symptoms. After titrating to therapeutic doses (paroxetine 20 mg/day, sertraline 50 mg/day, and combination of sertraline 50 mg/day and mirtazapine 30 mg/day in one patient each), impaired consciousness appeared. Electroencephalography (EEG) showed generalized slow waves with intermittent spike-slow-wave complexes. Intravenous injection of antiepileptic drugs improved EEG findings and clinical symptoms. After discontinuance of the abovementioned antidepressants, NCSE did not recur in any of patients. These reports raise the question of whether the newer antidepressants, like classic antidepressants, might also induce NCSE in the elderly, even when used at therapeutic doses. Physicians should consider monitoring for possible NCSE when using newer antidepressants in patients who may have low drug tolerability. Active continuous video-EEG monitoring is essential when behavioral and psychological symptoms or change in consciousness level is suspected.

[Moving from pediatric to adult care of epilepsy: improving transitions].

The common problems faced by adult patients with epilepsy are different from those facing pediatric patients. When adults with epilepsy work, marry, and give birth, they must deal with problems that they never experienced in childhood, such as gaining drivers licenses and accessing various medical and welfare services, in addition to the potential complications involved with their disease. Therefore, medical transitions from pediatric to adult care of epilepsy are crucial to ensuring that patients have a high quality of life. To solve the underlying problems that can block efficient transitions, we propose cooperation not only between pediatric neurologists and adult neurologists but between these practitioners and those from other disciplines, such as psychiatrists. We also argue that collaboration among relevant societies and national education programs is necessary.

Chronic periodic lateralised epileptic discharges and anti-N-methyl-D-aspartate receptor antibodies.

Periodic lateralised epileptiform discharges (PLEDs) are uncommon transient electroencephalographic findings accompanied by acute brain lesions. A small proportion of PLEDs persist for more than three months and are called "chronic" PLEDs, the pathophysiology of which is still debated. Herein, we report a man with right hemispheric PLEDs which lasted for more than 14 months and mild left hemispatial neglect after he experienced status epilepticus. Although MRI was normal, positron emission tomography revealed right temporo-parieto-occipital hypometabolism, which coincided with the source area of PLEDs estimated by magnetoencephalography. In addition, levels of anti-N-methyl-D-aspartate (NMDA) receptor antibodies and granzyme B were found to be high in the cerebrospinal fluid. Following two courses of steroid pulse therapy, the patient's left spatial neglect improved and the PLEDs were partially resolved. These findings suggest that the chronic PLEDs present in this case were an interictal phenomenon and that their pathophysiology involved autoimmune processes.

Experiential auditory hallucinations due to chronic epileptic discharges after radiotherapy for oligoastrocytoma.

Experiential auditory hallucinations have been reported in patients with epilepsy. We report the case of a 46-year-old woman with a history of more than three years of experiential auditory hallucinations caused by chronic epileptic discharges, which developed after radiotherapy for an oligoastrocytoma in the left temporal lobe. Electroencephalography revealed frequent spikes in the left temporal lobe. In response to clonazepam, but not antipsychotics, her auditory hallucinations almost completely disappeared and spikes were reduced. Her auditory hallucinations exhibited the characteristics of first-rank symptoms of schizophrenia, however, the content of experiential auditory hallucinations endured by our patient suggested an epileptic origin. We believe that the persistent subictal discharges, in combination with hyperexcitability of the temporal neocortex near radiation-induced necrotic lesions, were the cause of the auditory hallucinations.